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displaced scaph
oid. Postop xrays at 2 months when he is left free of pop. Back to work driving himself. There was communition at the radial and volar border. The xrays out of pop which will be uploaded in due course as the xrays are with the patient. You don't need to removed the screws and if you need to due to infection etc god help us
Do we have to remove the screw later?
ReplyDeleteThe fracture line is still visible...
ReplyDeleteu must be having a microscope to c the line aha
ReplyDeletefixtion of hand fractures has a definite advantage in terms of very early functional recovery and complete return to pre op function levels
ReplyDeleteDo not agree that fracture is undisplaced. CT scan should have been done. For me its displaced, and would definitely do a herbert, may be consider dorsal percutaneous approach. I know you like it that way. No cast after surgery, defeats the purpose.
ReplyDeleteIn Fractures of Hand and Wrist by David Ring 2007, he says we can fix type A Herberts(undisplaced, less angulated ones) if the patient doesnt want prolonged immobilisation or is a sports related person..
ReplyDeleteOtherwise type A Herbert's immobilisation may be attempted
Text books are the authors opinion. Text book of 07 would have been writen in 2004 or 5. Books are at least 4 to 5 years old by the time it is published and not upto date. Ofcourse one needs to be guided by experience of experts but you can cut the edge if it does not harm. Even if mildly displaced, one should reduce percutaneously reduce by joysticking and fix it. fracture shaft tibia also heals in POP. Dont we fix it. I had a medical student who wrote the final mbbs exams few weeks after percutaneous fixation and brace. My opinion today that percutaneous fixation is the standard of care today if there is no communition SO AT NOT TO FORESHORTEN IT when compressing. The trick it to use 4 mm shorter screw than the measured k wire. Guy are grafting and fixing non unions percutaneously if angular deformity is absent. The technique is simple and reproducible.
ReplyDeleteOFcourse i had a case wherein the screw(local titanium herbert screw jammed with damaged head protruding by 2 mm. I had to burr it out with a wrist scope and luckly no metal debris was found on the xray and the fracture united within 6 weeks. we have done 6 cases so far and all have united at 6 weeks.
jake
a lil un related question...on one side,clinical experience and instincts that a surgeon acquires first hand (as jacob sir puts it, along with the bias in-built in it).. on the other side,quality workshops/seminars (not the CME hrs ones!!), good evidence based literature, "authentic" text books..now how does an experienced surgeon like u weigh both of these? or in other words how much does the latter influenze the former??..or should it influenze at all (if there s a conflict between both)???
ReplyDeleteOh yes. Thats a good one. I think both are 2 sides of the same coin. One needs to listen, read attend workshops the cadaveric variety early on in orthopedic life, gain experience and see the motor skill what one can perfect and then cut the edge with it. The problems on only following literature is, are we upto the same level of skill or bull as I call it. I remember meeting Peter Campbell in Cologne long before he came to India where him he said that he is the president of the Ausssie no bull shit shoulder asssociation. There are magicians who can do magic with their hands , others lesser mortals like us work harder feel more, using the distal ends of our fingers to feel what the Imaging can't do. When robots take over surgery (TKR) etc the tactile impulses may become less important. This is going to popularise in the next 5 years if not not another banking Fiasco. Mind you what we say today will be disproved (even science) tomorrow unlike the Ayurveda whichI believe is an art and not science. May be the magnet(cyclotron) too is the worst of both.
ReplyDeleteThe CMe hours is the biggest joke. We had Gynecologists and cardiologists for the revision meeting at Kannur. Yes we come thru the pelvis and walk with the skeleton and go thru the the heart. Thats is enough literary Diarrhoea for the night. Listening to Yan Garbarek on the nadaswaran with zaKIR HUSSAIN ON THE TABLA.
Haddad and Goddard reported union rates approaching 100%, excellent functional results, rare complications and return to manual labour within five weeks after percutaneous fixation and immediate post-operative mobilisation. (1)
ReplyDeleteIn a prospective randomised trial of 25 full-time military personnel with acute nondisplaced fractures of the waist of the scaphoid, faster radiological union and return to military duty was reported after percutaneous cannulated screw fixation compared with cast immobilisation.(2)
A cost/utility analysis of open reduction and internal fixation versus cast immobilisation for acute nondisplaced fractures of the mid-waist of the scaphoid suggested that the former is cost saving from the social perspective.(3)
All the above were level ii- iv studies
The only level-1 study (prospective RCT) by McQueen(4) also gives good results with “non-displaced fractures” treated by Screw fixation in aspects related to rapid return to work , quicker time to union and low complication rate.
Agreeing fully that Percutaneous screw fixation has become the standard of care even for non displaced fractures of the scaphoid as said in 4 papers which includes one level- 1 study in a journal with very high impact factor..
Ref:
1. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg [Br] 1998;80-B:95–9.
2. Bond CD, Shim AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg [Am] 2001;83-A:483–8
3. Davis EN, Chung KC, Kotsis SV, Lau FH, Vijan S. A cost/utility analysis of open reduction and internal fixation versus cast immobilisation for acute nondis-placed mid-waist scaphoid fractures. Plastic & Reconstructive Surgery 2006;117:1223–35
4. McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C. Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study. J Bone Joint Surg Br. 2008;90:66–71.
Many cutting-edge breakthroughs have been made by natural geniuses like Albert Einstein, Michael Faraday, Thomas Alva Edison, Ramanujan and others who had little formal education.Besides, many of the most famous IT entrepreneurare
ReplyDeleteeither college dropouts or persons without much formal education like Bill
Gates, Paul Allen, Larry Ellison, Steve Jobs, Michael Dell, Mark Zuckerberg etc